PDGM and Beyond

Home Health Billing

Need specific, temporary, or longer-term billing support? Let HPS relieve your billing headaches. Our seasoned professionals offer interim billing services that make transitioning to PDGM, managing claims, or helping you take control of your billing department easy and stress-free.

HPS Alliance

As the home health landscape continues to evolve—and regulations change—it’s important to stay informed. Leave the guesswork behind. Become a member of HPS Alliance to get continuous access to exclusive industry resources, ongoing education, and industry-leading consulting. Guarantee that you’re always up to date and that your home health agency is set up for success no matter what by becoming an HPS Alliance member today.


Interested in discussing your needs with a member of our team? Give us a call 615-399-7499 or click the link below to schedule a callback.

Is Your HHA Leaving Money on the Table Under PDGM?

The Patient Driven Groupings Model (PDGM) – known as the most sweeping change in home health reimbursement since October 2000 – continues to live up to the hype surrounding its launch on January 1 of this year. Simply put, PDGM has proven to be a handful for most HHAs. Agencies across the nation are trying to figure out best practices for success under the new payment model 

Here are the Top 5 areas of focus for agencies to avoid significant losses under PDGM: 

Intake/Admission Deficiencies
  • Referral Order & Confirmation of the physician that will follow the patient in home health. 
  • FacetoFace Acknowledgement that a facetoface encounter did occur, and that the agency obtained a signed, dated encounter note where the practitioner addressed/treated the patient for the primary reason the patient requires home health. 
  • History & Physical, including Discharge Information – the H&P and discharge information are needed for multiple reasons, but the most important include: 
    •  Medical necessity documentation to support home health 
    •  Diagnosis coding in the medical record confirmed by a physician  
    •  Status of the patient stay and discharge date (It’s imperative under PDGM to understand whether the patient was an official admission and, if so, the exact discharge date that must be reflected on home health claims.) 
  • Medicare Eligibility Verification – You must verify that the patient is a traditional Medicare patient and establish if there have been previous home health episodes to determine if the new admission is early or late.
Untimely Signed Orders

Agencies must be diligent about getting signed orders returned so that they can efficiently complete billing. Cash flow is a universal issue under PDGM. Requests for Anticipated Payment (RAPs) are being paid at 20% of the anticipated 30-day payment amount, which gives agencies an even greater incentive to get orders back as quickly as possible. Final claims can now be filed at the end of each 30-day payment period, but the glaring requirement to do so is having all orders back from the physician. 

Lack of Interdisciplinary Collaboration on OASIS-D1

The OASIS has a huge impact on the PDGM HIPPS code calculation in the aspect of the Functional Impairment Scoring, which comes from the Activities of Daily Living (ADL) section of the OASIS. M1800-M1860 (except M1845) and M1033 are the items used in the calculation. This section includes the only items from the OASIS that are used in the PDGM scoring, and this is the only chance for agencies to impact the scoring from OASIS as it relates to the increase in reimbursement.  

From a medical review standpoint, these OASIS items are the first steppingstone in supporting medical necessity of therapy. It is a well-known fact that therapists are trained to functionally assess patients differently than nurses. It is also a fact that if nursing is ordered, then nurses must complete the comprehensive assessment of the patient. In this case, it is imperative that interdisciplinary collaboration exists between the nurse and the therapist to ensure the OASIS items reflect the functional status of the patient as will be recorded in the therapy documentation and care plan. 

Institutional vs. Community Mishaps

Under PDGM there is a significant difference in the casemix weight for a patient that receives Institutional credit and one that is Community. To receive Institutional credit, the patient must be officially admitted and discharged from an acute care hospital or qualifying post-acute facility where the discharge date is within 14 days prior to the start of the HHA 30-day payment period. The final claim for the 30-day payment period should include the appropriate Occurrence code with the corresponding discharge date from the facility that triggers the review of Institutional status in the casemix weight calculation. If the Occurrence code is missing from the claim and the facility claim is NOT in the Medicare claims processing system, the agency stands to lose the Institutional increase in casemix weight, which could be 40% higher than Community.

Lack of Monitoring LUPAs & PEPs

The Low Utilization Payment Adjustment (LUPA) and the Partial Episode Payment (PEP) Adjustment are the two most significant payment adjustments that agencies can receive and sometimes self-induced. LUPA adjustments occur when the LUPA threshold is not met for the given 30-day payment period. While agencies will have LUPAs – and it is NOT advised to ever attempt to avoid them 100% – there is wisdom in monitoring them to ensure that your agency is not allowing them to occur unnecessarily. Some of the thoughts behind this is primarily missed visits. Missed visits that do not get rescheduled in a timely manner could cause a LUPA to occur. Under PDGM, the LUPA thresholds are specific to each of the 432 case-mix groupings and will likely be different from one 30-day payment period to the next. Agencies should monitor each 30-day payment period individually to ensure they fall under the LUPA threshold for each. 

PEP adjustments occur as the result of a patient being discharged and readmitted or transferred between agencies during the same 30-day payment period. One of the significant concerns under PDGM is agencies consistently discharging and readmitting patients due to a facility admission in order to receive Institutional credit in the subsequent 30-day period. Agencies should consider asking if a PEP adjustment will result and, if so, whether the benefit of Institutional credit will outweigh the effect of the PEP adjustment.   

PDGM is the new reality for HHAs, and it isn’t going anywhereLike it or not, HHAs must learn to live with this new model and structure their processes so that they can begin to thrive under PDGM.  

Healthcare Provider Solutions provides billing services to home care and hospice agencies across the country. HPS can assist agencies in reviewing processes related to PDGM implementation and can assist with billing and collections in form of outsourcing or training of your staff. HPS and eSolutions have been trusted partners for eight years. 

PDGM Insights from Our Blog


Monday Minute with Melinda

NOA, Hospice Medical Review & Sequestration is Back! (VIDEO)

By Melinda A. Gaboury, CEO / Posted on: December 27, 2021

This Monday Minute will review the TOP concerns moving into 2022, including the sequestration deductions beginning again. We want to share with you a couple of things on the three most important transitional things as we move into 2022 for…


Notice Of Admission: The Lowdown On The Request For Anticipated Payment’s Successor

By Melinda A. Gaboury, CEO / Posted on: December 15, 2021

Do you have questions about the transition from Request for Anticipated Payment to Notice of Admission in 2022? This article will detail what is the same, what is different, and how to navigate the crossover periods. The RAP has been…

Monday Minute with Melinda

Notice of Admission 2022: EMR Failures (VIDEO)

By Melinda A. Gaboury, CEO / Posted on: December 13, 2021

This Monday Minute will review the critical aspects of the Notice of Admission that includes the cross-over periods from 2021 and the necessity of access to the Direct Data Entry (DDE) system.


7 Steps for PDGM Success

For a successful transition to PDGM, Home Health Agencies must develop a thorough understanding of how PDGM changes will affect reimbursement and clinical operations. Agencies should take the following actions to begin preparation for PDGM:

1. Ensure that whoever is finalizing your agency’s ICD-10-CM coding fully understands that the primary diagnosis needs to be specific enough to meet the code list requirements that group patients into Clinical Groupings & the significance of coding all comorbidities/secondary diagnoses that are pertinent to the patient’s care plan and will impact patient care and the Comorbidity adjustment when calculating a case-mix grouping for PDGM.

2. Evaluate your current practice of providing therapy services. Determine how to provide therapy effectively for patient care and outcomes while containing costs. Consider utilizing therapy assistants, telehealth/remote monitoring, etc.

3. Evaluate your HHA’s current revenue cycle process. This will allow you to establish whether or not the agency will need to add staff or outsource billing to manage the increased billing volume.

4. Review Calculations of the impact of the PDGM model on the agency’s reimbursement overall.

5. Review Calculations of the cash flow impact for the first months of 2020 to establish if your agency will need to consider building cash reserves prior to the implementation of PDGM.

6. Review the agency’s Clinical Operations. Establish patient care plans, determine the frequency and duration of visits, and decide how to best reinforce the expectations of continued excellent patient care and outcomes under PDGM.

7. Evaluate the current level of LUPA episodes and how that will vary under PDGM.

Melinda A. Gaboury

Melinda A. Gaboury


D. Mark Cannon, CPA

D. Mark Cannon, CPA


Aaron D. Carey

Aaron D. Carey